TX HHS Form 3076. Case Record Information Release

The TX HHS Form 3076, Case Record Information Release, is a crucial document that helps facilitate the sharing of information between individuals, organizations, or establishments and the County Indigent Health Care Program (CIHCP). This form is typically used in situations where an individual needs to authorize the release of their case record information to the CIHCP for eligibility purposes.

This form requires the applicant or recipient to provide specific information, including their name, case record number, and authorization for the CIHCP to obtain relevant data. The applicant must also specify the person or agency to whom the information will be released, as well as the type of request (general or specific) and the period covered. The form is valid for six months after the date signed.

Key features of this form include the required authorization for the release of case record information, the specification of the person or agency to whom the information will be released, and the limitation on the validity period. By using this form, individuals can ensure that their case record information is shared accurately and efficiently with the CIHCP.

• This form is used by individuals who need to authorize the release of their case record information to the County Indigent Health Care Program (CIHCP) for eligibility purposes.
• The form requires specific information, including the applicant's name and case record number.
• The form must be signed by the applicant or recipient, as well as any authorized representatives (such as a spouse or guardian).